Dear Parents,

Please fill out BOTH FORMS AT LEAST TWO WEEKS before any event at which you will be serving as a driver, chaperon, or helper.

AUTHORIZATION FOR RECORDS CHECK AND RELEASE OF RECORDS

            The undersigned has applied for employment or volunteer work with Cistercian Preparatory School, a private school in Irving, Texas.  I hereby authorize the release of any information or records held by any law enforcement agency or records-maintenance agency to Cistercian Preparatory School or its agent.  This authorization expressly includes, but is not limited to, records or information pertaining to any criminal convictions, charges, or inquiries.

            I further state that this authorization has been carefully read, and I fully understand the contents thereof, and have signed the same as my own free act.  By signing below I hereby agree to release and hold harmless Cistercian Preparatory School for any action taken pursuant to this Authorization.  I authorize Cistercian Preparatory School to rely on any information obtained pursuant to this Authorization in determining whether or not to offer me employment with the school.  

              Printed Full Name: ________________________________

              Soc. Sec. No.:_________________________________       

             Date of Birth:__________________________________   

            Driver’s License No.:____________________________

  Addresses for the last seven (7) years:

I certify that all of the information above is true and correct.

           Signature: __________________________________   

           Date: ______________________________________

      YOU MAY ALSO FAX THIS FORM TO 469-499-5440.          

 GEORGIA STATEWIDE (CHAMBLEE POLICE DEPARTMENT)

CRIMINAL HISTORY CONSENT FORM

            I hereby authorize ADP Screening and Selection Services to receive any

            criminal history record information pertaining to me which may be in the

            files of any state or any local criminal justice agency in the State of Georgia .

________________________________

            Full Name (Printed)

________________________________

            Street Address

______________________________________

                City, State, & Zip Code

________________________________                             ______________________________

            Date of Birth                                                                  Social Security Number

________________________________                              ______________________________ 

            Sex                                                                                  Race

________________________________

            Signature

_______________________________

            Date of Request                                                                CPS FAX: 469-499-5440